Journal of Gerontological Nursing

Blood Pressure Monitoring: Older Adults' Perceptions

Gloria Viverais-Dresler, RN, MHSc; Debra A Bakker, RN, PhD

Abstract

ABSTRACT

The purpose of this article is to report the qualitative findings on older adults' perceptions of blood pressure measurement and its meaning to their health. The convenience sample consisted of 51 community-dwelling older adults who were recruited from either wellness clinics or a senior citizens' club. Data were collected through in-depth audiotaped interviews. Participants' responses were analyzed by identifying topics, patterns, and themes. The following three themes emerged: provision of reassurance, decision-making leading to serf-care activities, and reliance on health care professionals. These findings can be used by community health nurses, especially those in gerontology to gain insight into how a sample of ofder adults perceived blood pressure monitoring. In addition, the findings can serve as guidelines for nurses in the provision of effective hypertension management with older adults.

Abstract

ABSTRACT

The purpose of this article is to report the qualitative findings on older adults' perceptions of blood pressure measurement and its meaning to their health. The convenience sample consisted of 51 community-dwelling older adults who were recruited from either wellness clinics or a senior citizens' club. Data were collected through in-depth audiotaped interviews. Participants' responses were analyzed by identifying topics, patterns, and themes. The following three themes emerged: provision of reassurance, decision-making leading to serf-care activities, and reliance on health care professionals. These findings can be used by community health nurses, especially those in gerontology to gain insight into how a sample of ofder adults perceived blood pressure monitoring. In addition, the findings can serve as guidelines for nurses in the provision of effective hypertension management with older adults.

Globally, the health needs of older adults are demanding more attention. In both the United States and Canada, there is an increasing number of older adults as well as an increase in life expectancy. As the older adult population increases, ways to maintain and optimize the health of this group become of greater concern for health professionals and health care planners (Pender, Murdaugh & Parsons, 2002; U.S. Department of Health and Human Services (USDHHS), 2000). It is not uncommon for an older adult to have at least one chronic illness and many live with multiple chronic conditions (Birchfield, 1996; Lubkin, 2002).

Traditionally, most research related to older adults has been quantitative and illness focused. According to Chappell (1990), "The health status of seniors has been studied primarily in terms of physical health, either the presence or absence of disease or the degree of functional disability or capacity." But during the past decades, the shift in health care emphasis from an illness-oriented system to one that advocates health promotion (Benner & Wrubel, 1 989; Epp, 1986; Pender et al., 2002; USDHHS, 2000) has prompted numerous studies that focused on factors affecting the quality of life for older adults (Cline, Willenheimer, Erhardt, Wiklund, Israelsson, 1999; Grundy & Bowling, 1999). Hence, it is important to develop programs aimed at encouraging older adults to adopt behaviors to help them maintain or improve their functional capacity and cope with life changes and chronic illness so they have more satisfaction with their lives on a daily basis.

Hypertension and heart disease are frequent chronic conditions found in both the United States and Canada (Frazier, 2002; Fleury & Keller, 2000; MacLean, 1999). Hypertension remains a critical risk factor for cardiovascular disease (CVD) in the older adult (MacLean, 1999; Robinson & Sloan, 2000; Sadowski & Redeker, 1996). The most frequently occurring cardiovascular diseases associated with hypertension in this age group are coronary artery disease and stroke (Meredith, Perloff, Mancia, & Pickering, 1995; Robinson & Sloan, 2000). It is currently recognized that treatment of hypertension in elderly individuals can be effective in the prevention of further cardiovascular events. In addition, the management of hypertension should begin with lifestyle modifications (Burgess, Cutler, Simons-Morton, & Willet, 1998; Preis, 1999; National High Blood Pressure Education Program, 1997). Thus, programs for patient education and prevention of hypertension are effective therapies for reducing CVD (Abbott et al, 1994; ChockaUngam et al., 1998; Hunink et al., 1997).

Previous research conducted by the investigators and others indicated a perception by older adults that blood pressure (BP) monitoring was an important benefit gained by attendance at nurse-managed clinics (Abbott, Alstad, & Yeo, 1989; Laffrey, Renwanz-Boyle, SIagle, Guthmiller, & Carter, 1990; Vrverais-Dresler, Bakker & Vanee, 1995). Healthy People 2010 (USDHHS, 2000) emphasizes the need for education and health screening, therefore, supporting older adults* perception of the importance of BP monitoring. Monitoring of BP, establishing BP screening programs, and teaching ways to promote healthy lifestyle changes are a part of the role of the community health nurse in the management of hypertension (Birchfield, 1996).

Only two research studies were found that investigated older adults' perceptions of BP and their health behaviors in relation to this potential health problem. These studies were conducted more than a decade ago (Abbott et al., 1989; Laffrey et al., 1990). Awareness and recognition of older adults* perceptions of health promotion strategies and activities are important in meeting health care needs and improving quality of life. Therefore, it is important to study older adults' perceptions and their understanding of BP screening and the consequences of hypertension.

Information reported in this article is part of a larger study that investigates health promotion activities of older adults residing independently in their own communities. This article presents the qualitative findings from a group of older adults on their perceptions of BP measurement and what it means to their health. The participants included older adults living independently, who attended either community clinics managed by public health nurses or sought health services through their family physicians. The purpose of this study was to gain insight into older adults' perceptions and activities related to BP.

METHOD

Sample and Setting

Following approval of the university's ethics review committee, the sample of older adults was obtained through investigator-made contacts with public health nurses who managed senior wellness clinics and the president of a senior citizens* club. A research assistant attended each wellness clinic and the senior's club to introduce the study and to invite adults to participate in the study. The eligibility criteria for participants included men or women ages 65 and older, living independently in the community, and who had a family physician. Purposeful sampling was used to recruit individuals who could provide a rich description of the phenomena of interest - the meaning of BP monitoring.

Table

TABLE 1CHARACTERISTICS OF STUDY PARTICIPANTS (N =51)

TABLE 1

CHARACTERISTICS OF STUDY PARTICIPANTS (N =51)

An underlying assumption was that older adults' attendance at wellness clinics and family physician appointments would include BP monitoring as part of health assessment of this age group. For individuals willing to participate, informed consent was obtained and an interview in their home was scheduled. Therefore, the study participants were a convenience sample of 51 community-dwelling older adults. Although the responses from all older adults interviewed are presented as one group, the number of participants recruited from wellness clinics was 40 and from the senior citizen's club was 11.

Data Collection

Data were collected by two interviewers. To enhance consistency, the interviewers completed a training session prior to conducting interviews. Interviewers followed an interview guide that provided prompts to aid in eliciting responses about BP. The interview was designed to be unstructured to allow participants to describe their perceptions and activities in their own words. The participants were asked four open-ended questions (Sidebar).

The questions invited participants to talk about their experiences at nurse-managed clinics and family physician office visits specifically related to BP measurement. They were asked about their understanding of having BP measurement taken, the kinds of information provided to them about BP, and the overall meaning of BP to the health of older adults.

All interviews were audiotaped and later transcribed verbatim. Using a questionnaire format, demographic data were collected on gender, age, marital status, living arrangements, first language, and educational level. In addition, the questionnaire collected information about participants* health, which included selfperceived health status, restrictions on activities of daily living, medication use, physician visits within the past year, and health problems.

Data Analysis

Descriptive statistics were used to provide a demographic and health profile of the group of participants. For the qualitative data, the narratives were analyzed to gain an understanding of participants' perceptions of BP measurement and its meaning by identifying topics, patterns, and themes according to the methodology outlined by Luborsky (1994). Topics were arrived at by coding the content of the participants* descriptions of their beliefs, attitudes, values, and behaviors.

Initially, the two researchers worked independently reviewing each of the transcripts to identify topics. To ensure the reliability of the data coding, each topic was reviewed by the two researchers as a team and consensus was necessary to retain a topic. Coding was the first step in organizing the data to determine shared common elements (Coffey & Atkinson, 1996; Luborsky, 1994; Streubert & Carpenter, 1999).

To facilitate interpretive analysis, transcripts were read multiple times and began with the identification of patterns that surfaced by interrelating the similarities and differences in the topics. Resultant themes emerged from the clustering and reordering of the identified patterns. This process yielded a description of the meaning given by the participants of the experience (i.e., BP monitoring).

RESULTS

Sample Profile

The demographic characteristics of the sample are displayed in Table 1. There were slightly more participants who were age 76 and older. The majority were women who lived alone. Given the gender and age distribution, the majority were widowed. With regards to perceptions of overall health, the majority reported "good" to "excellent" health status despite the presence of chronic illnesses and impairments (Table 2). In response to questions about health service usage, the majority (71%) of participants reported visiting their family physician four or more times during the past year.

PERCEPTIONS OF BLOOD PRESSURE MEANING

The findings are presented according to the three themes:

* Provision of Reassurance.

* Decision-Making Leading to Self -Care Activities.

* Reliance on Health Care Professionals.

These themes emerged from participants' behaviors and perceptions about BP measurement. Perceptions refer to participants' beliefs, attitudes, and values expressed as responses to the open-ended questions.

Provision of Reassurance

The theme, Provision of Reassurance, surfaced from topics that reflected emotions, beliefs, and opinions about monitoring BP. The first pattern conveyed a perception that regular monitoring of BP either at physicians' offices or at nurse-managed clinics provided relief from worry. Relief was experienced by the confirmation that hypertension did not exist, or, if present, it was controlled. For example, participants stated:

Table

TABLE 2PERCEPTIONS OF OVERALL HEALTH (N=51)

TABLE 2

PERCEPTIONS OF OVERALL HEALTH (N=51)

* "Well, I feel good when it's good."

* "It helps me to relax to know how my blood pressure is doing."

* "It just makes me feel better that I know that my blood pressure is keeping up nice."

Participants expressed feelings of relief because they could attend nursemanaged clinics between physician appointments to have their BP checked. Part of this relief came from knowing their BP readings before seeing their physician. One participant summarized this sentiment in the following way, **It [having BP taken at the clinic] helps me a lot because when I go every 2 months to the doctor I know what to expect."

There appeared to be an association between the emotion of relief and certain beliefs. Several statements indicated a belief pattern that BP monitoring could prevent disease and death. For example, one participant said, "If my blood pressure is normal it lets me know that Fm not going to drop on my feet or on the street or something." Such statements suggest the provision of reassurance by regular monitoring. However, some statements implied an erroneous belief that it was the procedure itself (BP measurement) that would prevent negative outcomes rather than screen for early detection of underlying disease. For example, one participant said, "Having your blood pressure taken gives you a sense... a feeling that you're not going to go off the deep end or you're not going to have a stroke." These patterns of beliefs and feelings strongly supported the identification of the theme Provision of Reassurance.

Decision-making Leading to Self-care Activities

The theme, Decision-Making Leading to Self-Care Activities, emerged from two identified patterns - individual awareness of BP as a health indicator and health information such as BP measurement is needed to make decisions and to take actions. Descriptions conveyed a reliance on BP as a health indicator. Participants viewed their personal BP measurement as being related to their health status. For example, one participant said, "It [a normal BP reading] just means that the state of my health is stable." Another stated, "It's [BP measurement] important, otherwise a lot of people would have a stroke or something like that if they were not aware that they had high blood pressure." As well, another participant reported, "It [BP measurement] tells the elderly individual if it goes too high you're liable to have a stroke or something else." These statements indicated an awareness of the relationship between BP measurements and health status. Also, these descriptions linked an increase in BP to underlying disease.

The other pattern was revealed by descriptions that conveyed participants' desires to use information to make decisions about controlling their BP. One decision involved controlling BP through the action of self-management. The essence of this decision is illustrated through the following quotes:

* "To know how to control it [BP], and how it's maintained.. .if it is high then I am warned."

* "In my condition with angina I have to make sure that I keep my blood pressure down... So, I think it's a very important thing to control it."

* "If your blood pressure is up you watch yourself a little more, you cut down on certain foods...."

* "It [BP] gives an idea if what you're doing, eating, or things like that if it's the proper thing."

By tracking their own BP readings, participants could make lifestyle decisions to manage their hypertension.

The other decision involved gaining input from health care professionals to take actions such as seeking medical care to control BP. For example, one participant said, "I think it is very important to have it [BP measurement] performed [at nurse-managed clinics], especially if you have high blood pressure. It saves you from running to the doctor's all the time and if it can be performed at these clinics, why not?" Participants valued the regular BP monitoring provided by nurses at these clinics because it aided their decision-making about seeking medical care.

Reliance on Health Care Professionals

The theme Reliance on Health Care Professionals emerged from patterns of participants' interactions with physicians and nurses in the monitoring and managing of BP. The patterns underlying this theme reflected older adults' desire for regular contact with health care providers for BP monitoring and also the nature of the information shared about their BP.

For participants, the act of having a health care professional take their BP on a regular basis indicated they interacted with caring professionals who demonstrated concern for their patients' health. One participant stated, "You should feel that they are really concerned over you by having it [BPJ taken like that," Furthermore, having the procedure performed regularly showed that health care providers were continuously monitoring older adults' health and were ready to intervene if BP readings were high. For example, one participant said, "Well, I think he's interested in my well being and he's [physician] going to help me.. .maybe he'll change a pill...." Another said, "The nurse tells me if it's high or low and last time she sent me to the doctor's because she thought it was high."

There was an expectation that BP measurement be performed each time participants visited their family physician. Also, individuals who attended nurse-managed clinics indicated clearly that BP measurement was one of the main reasons they attended the clinic. In fact, some individuals stated they no longer attended nurse-managed clinics because regular BP measurement for all attendees was discontinued. For those individuals with known hypertension, regular BP checks were viewed as particularly important. For example, a participant said, Tm very much guided by blood pressure. It would be nice to be examined once a month...."

Another perception in relation to this pattern of desire for regular contact with health professionals was that BP measurements were taken because the information was important to health care providers. These descriptions implied that the physician was solely in charge or responsible for patients' BP levels and that some older adults assumed passive roles in the monitoring or controlling of their own BP. The following are examples of this belief:

* "I think he wants to make sure for himself, that's what I think he does."

* "I like having it [BP] taken because I think he [family physician] should know it... and if there's any problems he will tell me."

* "I think that the doctor will keep it normal, just as normal as it can be...."

Another participant stated that her BP measurement was taken not because she requested it or was particularly interested in its level, but because the physician initiated the procedure. She said, "It's usually not my suggestion, the doctor does it to keep an eye on it. He should know what's happening to you."

In the second pattern, the nature of the information shared about their BP, individuals reported that nurses or doctors provided them with their specific BP values. The following quote conveys the message given by these participants: "They will tell you exactly what it reads." However, when specific values were given to participants, there was often a sense that these numbers had very little meaning to these older adults. For example:

* "The doctor just tells me what it is you know and it doesn't mean anything to me."

* "I usually ask him how high it is and he tells me so I know a little bit about it. I know it's 125 over 85 or something like that... and that's not bad but if it was too low or too high.. .he'd tell me."

Others reported that health care professionals indicated their BP level through statements such as, "It's good," "It's high again," "It's excellent," and "It's very good today." In some instances, individuals reported that their levels were given to them only if they asked, "Well he doesn't give it unless I ask... if I ask, 1Is it up or down?'... he'll say, Oh, it's good,' you know, or, 'It's up a little.' He doesn't usually give it unless I ask. I don't know if they're all like that or not."

Few descriptions were found reporting that explanations were provided when BP levels were elevated, for example, "He (physician) tells me what my blood pressure is and when I'm there; He tells me what I'm there for, and what I ask him he tells me." Regardless of the type of health professional contact, the information exchange related to lifestyle factors that affect hypertension was limited to dietary modification such as salt intake. However, the impression was that these individuals gained this information primarily from attending group educational sessions at the nurse-managed clinics and not at the time of individual blood-pressure measurement. In response to the open-ended question, "What information were you given about your blood pressure?" no participant, regardless of the site where BP was measured, reported receiving in-depth health teaching specific to their situation.

DISCUSSION

The present study explored older adults* perceptions and activities related to BP measurement. During the past several years, mass media campaigns have been launched to increase public awareness of risk factors for the leading causes of death in individuals older than 65, especially heart disease and stroke. Therefore, the importance of this qualitative investigation lies in gaining an understanding of older adults' perceptions of how BP relates to their health. Although the specific BP readings for participants were not a part of this study, all participants viewed BP monitoring as an important personal health care activity.

Responses to the question on the meaning of BP, as reflected in the themes, revealed that for this group of older adults, there was awareness of BP as an indicator of health status. Many in the sample linked BP to cardiovascular diseases and indicated an increased need for regular monitoring of BP in their age group. However, a physiological meaning of BP was not elicited in this group of participants. For example, none of the responses included any explanations on how BP related to the heart and blood vessels.

The nature of the open-ended question on the meaning of BP used in this study may not have prompted individuals to provide detailed explanations. Yet, this lack of physiological meaning raises the issue that perhaps it is difficult for individuals to make lifestyle changes (i.e., risk reduction) without a clear and basic understanding of BP and cardiovascular function. However, there is a paucity of research documenting the knowledge and awareness of older adults with respect to hypertension and cardiovascular diseases.

One study conducted in Canada using national survey data showed that awareness of the major causes of cardiovascular disease is low among older Canadians, especially among men and in those ages 65 to 75 (Kirkland et al-, 1999). Further exploration focusing on the knowledge and awareness of health risk factors in the older population is warranted if health promotion and disease prevention programs are to be aimed at motivating this population to make lifestyle changes.

Within the context of health promotion, self-care is regarded as one of the mechanisms for achieving health and wellness (Epp, 1986). The descriptions supporting the second theme, Decision-Making Leading to Self-Care Activities, fit well with Epp 's (1986) framework and Orem's (1991) definition of self-care. Orem (1991) defines seîf-care as "Activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being." The finding that this group of older adults was aware of the importance of BP as a health indicator reflects the first and necessary step in determining health status and initiating self-care activities. Furthermore, the patterns describing how some of these older adults used information to make decisions about their own care reflects a motivation to perform selfcare activities and take some responsibility for their own health.

The theme of reassurance suggests that elderly individuals believe BP monitoring is an important health need of their age group. Many participants had an accurate perception of BP monitoring as a screening procedure for early detection of disease and intervention. However, some individuals inaccurately perceived that the procedure itself was a preventative action against stroke and heart attack and this may provide them with a false sense of reassurance. This finding suggests strongly that health care practitioners need to explore, in greater depth, clients' perceptions of screening procedures such as BP monitoring. This is a finding that also requires further research.

Health care professionals need to be aware of the messages they aim to give and how clients may be perceiving them. For example, the sense of reassurance must be placed in the proper context. It must be clear that older adults' sense of reassurance comes from the understanding that the benefits of BP monitoring is based on the scientific rationale of early detection of hypertension and effective intervention rather than the procedure preventing stroke and heart attack. Similar findings about the sense of reassurance from screening tools have been noted in other client groups such as women undergoing mammography (Bakker, Lightfoot, Steggles & Jackson, 1998; Eardley & Elkind, 1990; Wardle & Pope, 1992).

The two themes of Provision of Reassurance and Reliance on Health Professionals may well be related to the uncertainty associated with the "silent killer" of hypertension. This uncertainty may arise because the older adult is unable to evaluate the presence of hypertension and to make decisions because of a lack of symptoms. This is an area worthy of further investigation and patient education.

Some participants indicated that the locus of control for BP monitoring and management rested with the health care professionals. At these clinics and in the literature, the question is raised about why older adults perceived BP measurement as one of the primary reasons for attending nurse-managed clinics (Laffrey et al-, 1990; ViveraisDresler et al., 1995). One wonders if the lack of symptoms and the uncertainty of not knowing if hypertension is a problem and the associated negative outcomes of hypertension realistically makes the older adult fearful and dependent on health professionals' opinion about whether they should be concerned or are at risk for cardiovascular disease.

Many participants identified the prescribing of medication as the primary intervention for BP changes and, in fact, only a few participants reported receiving some information on lifestyle changes such as diet, stress reduction, and exercise to control BP. In particular, isolated systolic hypertension, which commonly occurs in the older population (Fleury & Keller, 2000), can be managed with medications and compliance is enhanced with patient education (Chockalingam et al., 1998; Freís, 1999; Haynes, McKibbon, & Kanani, 1996). The sample in this study and older adults in other studies (Laffrey et al-, 1990; ViveraisDresler et al., 1995) have reported BP monitoring as one of the most important benefits of attending nurse-managed clinics.

The monitoring of BP also provides opportunities for education about lifestyle factors and other aspects of prevention. Therefore, it was a disappointing finding that older adults reported feedback about BP measurement from health care professionals to consist mainly of numerical values and did not include discussion on the importance or meaning of these values. Participants who received patient education usually reported being given information about medication. These findings suggest there are lost opportunities related to patient education in practice or, perhaps, the manner in which the information was provided may have influenced these perceptions.

Limitations

It is important to be cautious in making generalizations from the findings of the study because the sample of older adults who participated may not be representative of all older adults living independently in the community. The recruitment strategies and participant self-selection may have contributed to a particular sample profile of older adults who attend senior wellness clinics or senior citizen groups. The current qualitative study provides a beginning identification of the perceptions held by this sample of older adults related to BP measurement and the meaning they ascribed to their health.

Future research should include studies investigating the frequency of occurrence of older adults' perceptions to provide clinicians with a better sense of which perceptions are dominant, or most important to respondents. In addition, these studies could explore how these perceptions are related to demographic variables (i.e., do perceptions differ by gender, education, living arrangements as well as health-related variables such as number and type of health problems, perceived health status).

IMPLICATIONS FOR NURSING PRACTICE

Community health nurses, including gerontological nurses, are in ideal positions to provide more education to older adults about the preventive benefits of BP monitoring and clarify misperceptions. In fact, Birchfield (1996) outlines the role of the community health nurse in the management of hypertension as:

monitor blood pressure and weight; educate about nutrition and hypertensive drugs; teach stress management techniques; promote an optimal balance between rest and activity; establish blood pressure screening programs; assess client's current lifestyle and promote lifestyle changes; promote dietary modifications by using techniques such as diet diary, (cited in Stanhope & Lancaster, 1996, p. 589)

Gerontological nurses in primary health care settings can offer information that can assist older adults in appropriate BP monitoring which includes measurement techniques, reliable self-monitoring equipment, explanations of lifestyle variables to consider, and recognition of potentially serious cardiovascular events with actions to be taken. Perhaps these various strategies would provide older adults with tools to help relieve the stress associated with a silent condition such as hypertension.

There is a need to include teaching strategies that consistently apply the relationship of lifestyle factors to an individual's BP readings. Thus, there is a role for the gerontological nurse in teaching older adults about lifestyle factors such as diet, exercise, smoking, and the use of complementary therapies such Tai Chi and various types of relaxation strategies. These teaching measures would likely empower the older adult because they could initiate self-care activities that would contribute to their quality of life, help prevent cardiovascular disease, and provide older adults with some control in the management of their health (Kühn, 1999; Ross Si Presswalla, 1998).

CONCLUSIONS

Much has been written in the medical and nursing literature about the role of health professionals in the prevention of hypertension and related cardiovascular outcomes (Fleury & Keller, 2000; Robinson & Sloan, 2000; Winkleby, Barr, Jatulis, & Fortmann, 1996). The Healthy People 2010 national report (USDHHS, 2000) recognizes the need for planning health promotion and disease prevention strategies aimed at elderly individuals and hypertension. The National Heart, Lung and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2003) reported that since the 1970s there has been a decline in mortality from stroke in the older adult population which is largely attributed to improved diagnosis and control of hypertension.

The prevalence of risk factors for cardiovascular disease is widespread. A national survey in Canada revealed that more than 96% of individuals ages 55 to 74 have one or more of the major risk factors for cardiovascular disease (Langille et al., 1999). The themes identified from older adults' perceptions of BP monitoring in the present study provide direction for both clinical practice and future research. The ongoing challenge for health planners and providers is to consider the perceptions of older adults in the planning and delivery of health promotion programs that are relevant and appropriate to this population.

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TABLE 1

CHARACTERISTICS OF STUDY PARTICIPANTS (N =51)

TABLE 2

PERCEPTIONS OF OVERALL HEALTH (N=51)

10.3928/0098-9134-20040101-09

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